1

Team Approach: Multidisciplinary treatment of Hip

fractures in elderly patients - Orthogeriatric care

Wender Figved, MD, PhD1 Marius Myrstad, MD, PhD2 Ingvild Saltvedt, MD, PhD3,4

Merete Finjarn, RN1 Liv Marie Flaten Odland, RPT, MSc2

Frede Frihagen, MD, PhD5,6

1Department of Orthopaedic Surgery, Baerum Hospital, Vestre Viken Hospital Trust, Norway 2Department of Internal Medicine, Baerum Hospital, Vestre Viken Hospital Trust, Norway

3Department of Geriatrics, St Olav Hospital, University Hospital of Trondheim, Trondheim, Norway 4Department of Neuromedicine and Movement science, Norwegian University of Science and Technology (NTNU),

Trondheim, Norway 5Division of Orthopaedic Surgery, Oslo University Hospital, Norway

6Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway

E-mail address for W. Figved: wender.figved@vestreviken.no ORCID iD for W. Figved: 0000-0002-8201-9818

Department of Orthopaedic Surgery Baerum Hospital

Vestre Viken Hospital Trust 1349 Gjettum

Norway

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Team Approach:

Multidisciplinary treatment of Hip fractures in elderly patients – Orthogeriatric care

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Take Home Points

• Patients with hip fractures are best managed by a multidisciplinary team.

• The multidisciplinary team consists of orthogeriatrician, orthopedic surgeon,

anesthesiologist, orthopedic and/or geriatric nurse, occupational therapist,

physiotherapist, clinical pharmacologist and may also include other professions, such as

endocrinologist, nutritional therapist, and social worker.

• Key factors include perioperative assessment and early surgery, comprehensive geriatric

assessment (CGA), multidisciplinary in-ward assessment including discharge planning,

treatment and rehabilitation, and secondary fracture prevention.

• Current evidence show that older people receiving multidisciplinary treatment for hip

fracture, CGA, and systematic secondary fracture prevention, have reduced morbidity

and mortality, a lower risk of subsequent fractures, and are more likely to return to the

same location they lived in before hospital admission.

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Introduction

Hip fractures are among the most common, serious and costly fractures in the elderly.

The global prevalence in 2010 was 2.7 million. Due to population ageing this is expected to

increase to about 4.5 million cases in 20501.

Hip fractures are frequent in older people2, and are often a result of falls due to frailty

with sarcopenia, impaired balance and gait. Hip fracture patients share many common

characteristics with geriatric patients, as most of them are old, frail, have reduced physical

functioning, increased risk of falls, cognitive impairment and dementia, multi-morbidity, and

polypharmacy. The broad team approach that is necessary to address this spectrum of conditions

in an acute setting is often referred to as comprehensive geriatric assessment (CGA)3. When

organized in acute geriatric wards, comprehensive geriatric care improves outcomes for frail

older patients4,5. After orthogeriatric care was introduced in the United Kingdom (UK) the

mortality among hip fracture patients has decreased6,7.

Hip fractures in older individuals are associated with poor short and long term prognoses,

with increased mortality, and negative impacts on function, mobility and quality of life. Many

patients remain disabled with reduced gait function for the rest of their lives. Hip fractures have

substantial sosioeconomic consequenses due to costs related to acute and post-acute institutional

care, and need of assistance in daily living.

Surgical care is crucial, but with the goal to improve the patients’ prognosis and achieve

better function and quality of life, a wider approach is necessary. Recently, studies have

demonstrated that even older hip fracture patients benefit from CGA as part of a

multidisciplinary orthogeriatric treatment with improved mobility, function and quality of life,

and that ortogeriatric care is cost-effective8-10.

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In this review, we aim to address multidisciplinary and orthogeriatric treatment for

elderly hip fracture patients, presenting a hip fracture patient admitted to an orthopedic ward.

Clinical Scenario

The patient is an 82-year-old woman with a medical history of hypertension treated with

amlodipine and candersartane, hyperthyroidism treated with levothyroxin, and who underwent a

successfully surgically treated spinal stenosis decompression 20 years earlier, and type-2

diabetes treated with metformin. Due to paroxysmal atrial fibrillation, she uses oral

anticoagulation treatment with warfarin to prevent ischemic stroke. Her vision is impaired due to

cataract of one eye and an arterial thrombosis of the other eye. She lives with her husband in an

apartment, with no community services. She had no previous cognitive impairment and no

problems walking without aids. While shopping, she slipped on a carpet and sustained a fall from

a standing height, injuring her left hip. She also suffered a mild head trauma. An ambulance

brought her straight to the emergency department (ED) of her local hospital, where an elevated

serum glucose level of 23 mmol/L was treated with a fast-acting insulin analog. Intracerebral or

subdural bleeding was ruled out with an acute cerebral CT scan. Radiographic evaluation

revealed a displaced left femoral neck fracture and mild (asymptomatic) osteoarthritis (Fig. 1).

Her body mass index (BMI) was 22.7 kg/m2, and her American Society of

Anesthesiologists (ASA) score was 3. Her electrocardiogram (ECG) was normal. Laboratory

studies include an albumin of 2.7 g/dL, a hemoglobin of 10.3 g/dL, international normalized ratio

(INR) of 1.3, and a vitamin D of 68 nmol/L. Serum electrolytes and renal function were normal.

While still in the ED, a multidisciplinary patient pathway was planned (Fig. 2).

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Team Approach

Orthogeriatric care is performed according to the same principles as CGA, and is

performed by an interdisciplinary team of professionals specialized in treatment of elderly

patients. Usually, the team is comprised of a geriatrician and an orthopedic surgeon,

collaborating with a nursing staff trained in geriatrics, physiotherapists, occupational therapists,

clinical pharmacologists, and in many cases a nutritionist and a social worker. The team

collaborates both informally and in regular interdisciplinary meetings to discuss the patients,

develop individual care plans, and define short- and long-term goals for each patient. CGA

includes the use of standardized assessment tools for evaluation of cognitive and physical

function. Pain assessment should by performed by using numeric or verbal rating scales.

Discharge planning start as early as possible. All team professions have dedicated

responsibilities.

The orthogeriatric hospital ward should have sufficient space for patients to move

around, available aids for mobility and self-care, and calendars and clocks as cues for

orientation. CGA focuses on functional status and the patient’s socio- and environmental

situation. Collaboration across sectors as well as with the patient and her caregivers is necessary

to achieve continued rehabilitation and a successful discharge. The aim is to provide optimal

medical treatment, avoid inappropriate drug prescriptions, to prevent complications, start

rehabilitation as early as possible, and plan for discharge from hospital to further rehabilitation.

Anesthesiologist and orthopedic surgeon

Communication between anesthesiologist, orthopedic surgeon, and orthogeriatrician, is

crucial to secure the total medical care throughout the patient pathway. Patient factors and frailty

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should be discussed, with the goal of not delaying surgery more than absolutely necessary. Co-

morbidity should be acknowledged and accounted for11,12. The International Fragility Fracture

Network Delphi consensus statement on the principles of anesthesia for patients with hip

fracture, released earlier this year, promotes the use of hypotensive neuraxial anesthesia in most

patients, and that anesthesia for hip fracture should be undertaken by an appropriately

experienced anesthetist. Anesthesia should be administered according to agreed standards at each

hospital, using age-appropriate doses, with the aims of facilitating early patient re-mobilization,

re-enablement and rehabilitation. Also, if used at all, intra-operative sedation should be adjusted

according to the patient’s age, frailty and comorbidities, to minimize the risk of delirium13,14.

Single-dose methylprednisolone may reduce both the prevalence of delirium and the severity of

fatigue after hip fracture surgery in older patients15. The anesthesiologist and the anesthesiology

nurse are also responsible for correct administration of perioperative antibiotics. The orthopedic

surgeon and the anesthesiologist should discuss the scope of the planned surgery, including

measures taken when using bone cement16, and measures taken when reversal of anticoagulants

are needed14. The orthopedic surgeon should consider the surgical treatment options according to

hospital guidelines and current evidence6,17.

After diagnosis, our patient’s preoperative assessment was conducted by the orthopedic

surgeon and the anesthesiologist on call. Several types of peripheral nerve blocks have been

studied, the femoral nerve block and fascia iliaca block being the most common14,18. Our patient

received a femoral nerve block on the left side while still in the ED. The patient was deemed

medically optimized for operative treatment, which was scheduled for the following day. Based

on the patient’s physiological age, medical comorbidities, and activity level, hospital guidelines

recommended a left total hip arthroplasty with a cemented femoral stem, and the anesthesiologist

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planned for a spinal anesthetic. The operating room (OR) team consisted of an anesthesiologist,

an anesthesiology nurse, two OR nurses, one consultant and one resident orthopedic surgeon.

Prior to surgery, the safe surgery checklist was completed, with the use of bone cement reported

as a concern16,19, also securing the timely administration of antibiotic prophylaxis. She received 1

g tranexamic acid intravenously to reduce bleeding20,21. She underwent the surgery as planned,

with a duration of 53 minutes, associated with 280 mL of blood loss. After 3 hours in the

postoperative ward, she was transferred to the orthopedic ward for further rehabilitation and

multidisciplinary treatment. Her postoperative hemoglobin was 9.9 g/dL. Postoperative

radiographs were examined by the orthopedic surgeon (Fig. 1).

Orthogeriatrician

Early and optimal assessment and treatment of concomitant medical conditions is crucial.

A thorough clinical evaluation and laboratory tests should be performed regularly, in order to

recognize postoperative complications such as anemia, infection, dehydration and electrolyte

disturbances, and perioperative decompensation of comorbidities like diabetes, arrhythmias, and

heart failure. Oxygenation must be measured regularly; with oxygen supplies if saturation is low.

Blood transfusions should be given if needed. Monitoring of supine and orthostatic blood

pressure is important, and cardiovascular drugs have to be adjusted according to these

measurements.

A clinical medical review should be performed by the geriatrician, in cooperation with

the clinical pharmacist, in order to avoid inappropriate drug treatment. All patients should

receive acetaminophen, and a majority needs an opioid. NSAIDs should be avoided due to a high

risk of side effects among frail elderly patients, including bleeding, kidney failure, and

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exacerbation of congestive heart failure18. Adjustments of anticoagulation therapy and

antithrombotic prophylaxis should be individually tailored. Constipation is common among hip

fracture patients, and treatment with laxatives should start the first postoperative day.

Information on pre-fracture cognition can be obtained from family and caregivers.

Delirium is a complication that affects up to 50% of elderly hip fracture patients, with the highest

prevalence seen in patients with cognitive impairment10. Delirium is associated with increased

length of hospital stay, increased mortality, and development of dementia22-24. Delirium

assessment should be performed pre- and postoperatively, and the risk can be reduced by

proactive geriatrics consultation, as well as medical and anaesthesiological considerations13,15,25.

We suggest using 4AT, a rapid delirium screening tool that could be used by all healthcare

workers26. The Confusion Assessment Method (CAM) is an alternative27. Patients with delirium

during hospital stay, especially with no diagnosis of dementia, should be followed after

discharge with cognitive assessment.

Our patient had a mild postoperative anemia. Oral anticoagulation therapy with warfarin

was re-started on the first postoperative day. Low molecular weight heparin was given until INR

reached therapeutic levels, as her international normalized ratio (INR) was 1.3. She received

lactulose to prevent constipation. Daily clinical evaluation did not reveal any signs of infection.

She had a visual analogue scale (VAS) pain score of 7 out of 10 on the first postoperative day

and was treated with oxycodone slow release 5 mg x 2 and paracetamol 1 g x 4 daily, with

additional oxycodone 5 mg as needed18. A note was made to refer to an ophthalmological consult

at discharge for her visual impairment.

Orthogeriatric ward nurse

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Use of aids for impaired hearing or vision is important for orientation. Early mobilization

with weight-bearing exercise programs and participation in activities of dailiy living (ADL)

should be executed by both physiotherapists and nursing staff. Urinary catheters are used

perioperatively, but should be removed on the first postoperative day: Patients should be scanned

for residual urine and checked for urinary tract infections. Frequency of defecation should be

registered, especially in patients with cognitive impairment. Nutrition should be supported, and

food intake monitored if patients are undernourished or have poor appetite. Nutritional drinks

may be used before and after surgery. Screening for malnutrition should be performed, and an

individual nutrition plan should be made if indicated, in cooperation with a nutritionist28. An

individual rehabilitation plan with short-term goals based on previous function, cognition, type

of surgery, and motivation, should be created. A long-term goal based on the current status and

the pre-fracture function should be defined in the discharge report.

Our patient had a 4AT score of zero at admission and on the first postoperative day. On

the second day, she had a a 4AT score of six: She could not recall the name of the hospital, and

was not able to state seven or more months of the year backwards starting with December. Based

on information from her family members, she had not had any cognitive problems earlier, and

her symptoms was considered to be caused by a postoperative delirium. Her symptoms resolved

after treatment with intravenous fluids, and non-pharmacological treatment, including extra

nursing staff, emphasizing verbal re-orientation and environmental shielding. No indication was

found for pharmacological treatment. Her 4AT score the following day was zero.

Discharge planning is started on admission. Destination for discharge is based upon the

patients’ functional and medical status, place of living, and the patients’ and caregivers’

motivation. The fittest patients may be discharged to their own home with assistance from home-

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based primary care services, including physiotherapy at home, in a physiotherapy clinic, or at a

day-time rehabilitation center. Most ortogeriatric patients need institutional rehabilitation, while

some are too frail and may be discharged to a nursing care facility. Communication with general

practitioners, rehabilitation facilities and nursing homes about individual patients are mainly

based upon discharge reports, covering medical treatment, drug regimens, caring needs,

physiotherapy and recommended follow-up.

Occupational therapist

Independency and the ability to carry out ADL are important for most individuals, and

among the strongest predictors for survival in geriatric patients29. While primary ADL (pADL)

include the ability to mobility, eating and other basic functions, instrumental ADL (iADL)

describe more complex functions like use of public transport and taking care of personal

economy. Observation of function and assessment of ADL with standardized tools are the main

tasks of occupational therapists in the CGA as well as in ortogeriatric care. The Barthel ADL-

index (pADL) and the Nottingham Extended ADL Scale (iADL) are among the most used tools

for this purpose30,31. As cognitive function plays an important role in ADL, the occupational

therapist uses assessment tools, as well as interviews with caregivers, for screening on cognitive

impairment32.

Physiotherapist

The ability to remain mobile with safe and efficient gait, is an essential part of autonomy

and quality of life33. Hip fractures represent a threat to the ability to live and walk independently.

Early mobilization with weight-bearing activities after hip surgery is highly recommended, and

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should be initiated within the first postoperative day6. The physiotherapist’s main role in the

interdisciplinary team, is to initiate progressed activity and exercise/training with an individual

and structured approach, based on early assessment of physical function. Pre-injury level of

mobility may be recorded retrospectively by a New Mobility Score (NMS)34,35. The total of

NMS functional level before fracture, age and fracture type may facilitate prediction of the short-

term potential of independency in functional mobility during admission and discharge status36.

The NMS score in our case was 7/9 points, indicating a relatively good pre-injury status.

Grip strength at admission can help clinicians better identify high-risk subjects, who

could benefit from intensive multi-domain programs37,38. Assessed grip strength in this case

revealed a lowered mean score, which may indicate global muscle weakness and frailty. Physical

performance and mobility are strong determinants of mobility after hip fracture. The short

Physical Performance Battery (SPPB) characterizes lower extremity function, and is regarded as

an objective outcome of physical performance for elderly, preferably as near discharge as

possible39,40. Components of the SPPB (chair stand, gait speed and tandem stance) are also

predictive for falls. SPPB completed at day 3 after surgery in this scenario gave a low total score

of 2/12, indicating increased risk of falling, and risk of functional decline in the early post-

surgery phase. SPPB has been shown test-retest reliable, and is recommended re-tested as part of

further rehabilitation41.

In order to prevent further falls with injuries, a falls assessment was performed during the

hospital stay, based on the case history from patient and caregivers on previous falls and mobility

problems, the cause(s) of the present fall, and a clinical assessment of comorbidity, drugs,

muscle strength and balance.

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Fracture-Liason Service

The Fracture Liaison Service (FLS) aims to systematically identify, treat and refer all

eligible patients within a local population who have suffered a fragility fracture, with the aim of

reducing their risk of subsequent fractures. An FLS, consisting of a committed team of

stakeholders, employs a dedicated coordinator to act as the link between the patient and the

ortopaedic team, the osteoporosis and falls prevention service, and the primary care system 42,43.

Our patient was assessed during hospital stay. She received vitamin D3, 100,000 IU, due

to her suboptimal level, and was started with calcium carbonate 500 mg/vitamin D3 800 IU

daily. In our FLS, hip fracture patients are offered anti-osteoporosis treatment as in-patients

based on the increased imminent risk of a new fracture, and hence a need to start treatment as

early as possible44. Also, we have found it difficult for many hip fracture patients to attend an

osteoporosis clinic for some time after the fracture. Our patient accepted, and received

zoledronic acid 5 mg iv after vitamin D levels were normal, and was referred to the osteoporosis

clinic for further follow-up45.

Clinical pharmacist

Inappropriate drug prescription is common among older patients acutely admitted to

hospital including orthopedic wards46,47. Inappropriate drug prescription might have negative

clinical impact in older patients48, and drug prescription is associated with risk of hip fractures in

older individuals49-51. Polypharmacy is common in older people52, and associated with frailty,

disability, falls, mortality, and increased risk of drug-related problems53,54. The role of the

clinical pharmacist is to identify and resolve drug-related problems. Examples are adverse drug

reactions, drug interactions and adherence problems. Possible effects of pharmacist interventions

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are reduced risk of delirium and other complications, improved adherence and less re-

admissions55. Critical differences in drug prescription between geriatric and orthopedic hospital

wards have been demonstrated56.

Our patient had hypothyroidism and insulin-dependent type 2 diabetes, both diseases that

may increase the risk of osteoporotic fractures. Over-treatment of levothyroxine is a risk factor,

and the lowest dose that provides treatment effect should be sought57,58. Patients with type 2

diabetes have an increased risk of fractures. Type 2 diabetes reduces bone quality rather than

bone mineral density (BMD)59. Older patients with type 2 diabetes have more frequent falls than

elderly individuals without diabetes60. This patient is also at risk of hypoglycemia and fall, and

good blood glucose control is important. The clinical pharmacist noted that levothyroxine should

not be taken at the same time of day as the newly added medication of calcium carbonate and

vitamin D3, and that a change in drug administration schedule usually minimizes or eliminates

this interaction61. On advice from the clinical pharmacist, the orthogeriatrician separated the

administration of the two interacting drugs, so that levothyroxine would be administered in the

evening. Due to her low INR at admittance, her warfarine dose was also adjusted, and the

discharge papers included a suggestion to her general practitioner to switch to a novel oral

anticoagulant (NOAC).

Follow-Up: Fracture-Liason Service

8 weeks after discharge, the patient presented to the outpatient clinic’s osteoporosis team

for a planned bone density measurement and evaluation. She was met by an orthopedic ward

nurse with osteoporosis training. Questions the patient may have on her surgery and other

matters pertaining to her hospital stay, can be answered by the nurse, if necessary after

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consultation with other professionals. She arrived with a walker. She had moved back into her

own home, after a 3-weeks stay at a rehabilitation facility run by the municipal health service.

Until now, she had received some home nursing, and physiotherapy a few times a week. She

now manages on her own, with some help from her husband. To assess the risk of future

fractures, the nurse will identify the risk factors for osteoporosis, conduct a dual-energy X-ray

absorptiometry (DXA) scan, and assess fall risk. If resources permit, BMD may be obtained

during the inpatient stay. Patient history and risks were assessed, including diseases,

medications, previous fracture, blood samples, family history of osteoporosis, dietary calcium

intake, smoking, alcohol, exercise, BMI, loss of height, and finally a basic fall risk assessment.

She had no prior fragility fracture. She is a non-smoker, and reported a modest intake of

alcohol. The calcium intake in her diet was low, about 500 mg daily, and due to a

misunderstanding, she had stopped taking the prescribed calcium and vitamin D3, which was

prescribed for her after the hip fracture. BMI was within normal range, but she reported a height

loss of 5 to 6 cm. She reported some back pain episodes, but this had gotten better the last couple

of years. Fall risk had previously been identified by the physiotherapist and the orthogeriatrician,

and she was followed by a falls prevention programme: She was encouraged to uphold daily

activity by ability, as well as participation in training groups for the elderly who integrate

strength-balancing exercises. She was reminded of the importance of good blood sugar control,

in fear of hypoglycaemia and fall. She had scheduled an appointment with an ophthalmologist.

DXA is a technology that is widely used to diagnose osteoporosis, asses fracture risk, and

monitor changes in BMD62. Results of the patient’s BMD examination showed osteoporosis of

the hip; with a total T-score of -2.7 and -2.4 for the femoral neck (Fig. 3). In the column, she had

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a normal T-score of 0.6. and the lowest measured vertebra had a T-score of -0.2. Degenerative

changes or previous fractures in the lumbar region may give a false elevated T-score.

A Lateral Vertebral Assessment (LVA), a low-dose x-ray examination of the spine to

screen for vertebral fractures that is performed on the DXA machine, revealed compression

fractures in the Th10 and Th12 vertebrae, that were not known to the patient (Fig. 4).

The completed survey showed established osteoporosis. Based on fracture history and

age, recommended treatment was continuing zoledronic acid 5 mg intravenously per year, and

calcium carbonate 500 mg/vitamin D3 800 IU daily. The patient received a written report of all

findings and a treatment plan, as well as written information on preventive lifestyle advice in

order to take care of her bones and prevent future fractures. The patient will be notified of her

second infusion of zoledronic acid at 1 year postoperatively, with blood samples in advance. We

will consider the need for new BMD and bone-markers after 3 years, for assessment of need for

further treatment. Statistically, our patient now has a substantial lowered risk of a subsequent

fracture45,63,64.

Follow-Up: Orthopaedic surgeon

Routines for planned follow-up of hip fracture patients by orthopaedic surgeons differ

between health care systems and hospitals, and has been debated65. Our patient was scheduled

for a follow-up with radiographs 6 months postoperatively. She presented to the outpatient clinic

independently, walking without aids, having travelled by bus. She had no pain from her left hip.

She reported an Oxford Hip Score66,67 of 47 out of 48 points, due to slight problems climbing

stairs. Per hospital protocols, arthroplasties for femoral neck fractures are not routinely followed

beyond 6 months, but patients are encouraged to contact the outpatient clinic if needed.

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Discussion

There are different models of orthogeriatric care. Patients may be treated in orthopedic

wards with geriatric involvement organized either as consultant services on request, or with daily

consultative services, or orthopedic surgeons and geriatricians have shared responsibility and

treat patients together. Another approach would be initial treatment in an orthopedic ward with

transfer to geriatric wards postoperatively, and a third option is that patients are treated in

geriatric wards with orthopedic surgeons having responsibility for the surgical treatment. The

literature is still inconclusive as to which of these models are most beneficial. However, models

with an integrated approach with early involvement of a geriatric interdisciplinary team seem to

be superior compared with models using consultative services, or where there is a late

involvement of the geriatric team68-70.

This case demonstrates a patient receiving perioperative assessment and early surgery,

CGA, multidisciplinary in-ward assessment, treatment and rehabilitation, and secondary fracture

prevention. Without this team approach, she would have a higher risk of complications and poor

outcome due to many factors, such as new falls, secondary fractures and dependency on others,

due to untreated delirium, undiscovered and untreated osteoporosis, and unresolved inappropriate

drug prescription. During hospital stay, a treatment plan was made that was continued in the

rehabilitation facility and then in her own home. Rehabilitation was not stopped until she

achieved independent mobility.

Strong evidence supports use of an interdisciplinary care program for patients with hip

fractures: AAOS, NICE and Cochrane present useful guidance and evidence summaries5,6,8.

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Source of Funding:

The authors received no funding for this work.

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Fig. 1:

Radiographs of a displaced left hip fracture (left) with presence of mild radiographic

osteoarthritis, and postoperative total hip replacement (right) with a cementless acetabular cup

and a cemented femoral stem.

27

Fig. 2:

The multidisciplinary team approach to managing patients with hip fracture. Dark blue fields

indicate essential collaborative actions and patient contacts per day. Light blue fields indicate

suggested additional collaborative actions and patient contacts, that may be dependent on

hospital staff structure and availability. Different models may include additional professions,

either as part of the multidisciplinary team or as on-demand actors; such as endocrinologist,

nutritional therapist, social worker and others.

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Fig. 3:

Image and graphical result of Dual-energy X-ray absorptiometry (DXA) scan of the right hip

showing established osteoporosis, with a a total T-score of -2,7 and -2,4 for the femoral neck.

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Fig. 4:

Lateral Vertebral Assessment (LVA), a low-dose x-ray examination of the spine to screen for

vertebral fractures that is performed on the DEXA machine, showing vertebral compression

fractures in the Th10 and Th12 vertebrae.